Healthcare DICOM Migration Planning

Healthcare DICOM Migration Planning and Patient Authorization

Project Identifiers

Project Name:    Project ID:

Initiating Facility:    Receiving System:

Patient Information

Insurance and Clinical Summary

Scope of Data Transfer

Select the types of data and limits to be migrated for the patient named above:

Include all prior imaging studies (no date restriction)

Include studies within date range:

From:    To:

Include DICOM images

Include associated radiology reports (structured or free text)

Include secondary capture and derived images

Include private/vendor-specific DICOM tags (may include PHI)

Technical Migration Plan

Transfer Method(s):

Encryption in Transit:    Encryption at Rest:

Require anonymization prior to transfer    If anonymize, method:

Testing, Validation and Acceptance

Planned validation activities (check all that apply):

Visual comparison of sample studies

Pixel-level integrity / checksum verification

Verify report-to-study linking and metadata consistency

Verify worklist, routing, and modality connectivity where applicable

Operational Timeline and Rollback

Planned Start Date:    Planned Completion Date:

Security, Privacy and Legal Acknowledgments

By signing below the patient authorizes the transfer of protected health information (PHI) described in this form. The initiating facility and receiving system will implement appropriate administrative, technical, and physical safeguards to protect PHI during transfer and storage. Any subcontractor engaged to facilitate migration shall be bound by equivalent confidentiality and security obligations.

The patient understands that remapping of identifiers or anonymization may be required for compatibility and that remapped studies will retain a clear audit trail indicating original accession numbers and transfer events. The initiating facility makes reasonable efforts to ensure data integrity but does not warrant uninterrupted access once data has been accepted by the receiving system.

The patient retains the right to revoke this authorization in writing at any time prior to transfer; revocation will not affect actions already taken in reliance on this authorization. Revocations must be submitted in writing to the initiating facility contact listed below.

Authorization and Expiration

I hereby authorize the initiating facility to transfer my imaging records and associated reports as set forth in this plan to the receiving system identified above. I understand the nature and purpose of this transfer and consent to the actions specified.

HIPAA Privacy Acknowledgment: I acknowledge receipt of the facility's privacy practices and understand how my PHI will be used for this migration.

Sign Now